Open Dialogue in Nottingham

“The name Open Dialogue was first used in 1995 to describe two key features of the approach: the use of open family/network meetings and a set of principles for organising the whole psychiatric system that made dialogue possible.” Nottingham Open Dialogue group, September 2013

Back in early September I wrote about the conference I went to in Nottingham – Psychiatry beyond the current paradigm. One of the workshops at the event focussed on an innovative approach to mental distress and crisis work called Open Dialogue, and I promised to write more about it in a future post – so here goes.

Before going to Nottingham I had read briefly about the approach in Robert Whitaker’s book – Anatomy of an Epidemic. “Western Lapland in Finland has adopted a form of care for its psychotic patients that has produced astonishingly good long-term outcomes.” You can read more on Robert’s website here. Robert has subsequently referred to the Open Dialogue approach again in blogs and other writings, quoting it as a clear mandate for change. 

So, what happened at Nottingham? Well, first of all, hour one of the session was absolutely Powerpoint free. That was refreshing in itself. A group of people have been meeting informally in the city to look at what is happening in Finland, and several of them had agreed to lead this workshop. They introduced themselves, and explained that they were considering how Open Dialogue could be put into practice locally. They educate themselves at meetings, having a mailing list of about a hundred, and a core 16 – 18 people attend the meetings regularly. Originally they began as people with “lived experience”, but the group has now expanded to include some professionals “which has changed the dynamics”. 

What followed for the first half of the workshop was a dramatisation and replaying of an actual Open Dialogue meeting which had taken place in Finland some years ago. This was extremely powerful, as for those of us attending it really felt as if we were watching and listening to an actual meeting. The professionals involved listened for a long time without saying anything at all to both the person in distress and the close family members. Eventually, when they did speak, they shared their views amongst themselves and allowed the person and his family to listen in. Further dialogue between the whole group then followed, and throughout the session the sense of absolute crisis seemed to gradually ebb away through use of this continued dialogue. There is no video of the workshop, but if you want a feel read “The Story of Pekka and Maija” on pages 411- 414 of Jaakko Seikkula and Mary E. Olson’s article about the approach.

The second half of the Nottingham workshop was used to explore the Open Dialogue approach in more detail and for this a presentation was used, but again group members took turns to explore the different areas. Some of the key points for me were:

• Psychosis is a temporary, radical disengagement from shared communication practices.
• The need to create safety/trust to allow people to express deep fears.
• Stay with the situation as it is, and allow it to develop (without using specific “tools”).
• The reflection that the team does is in the family meeting.
• Results have been better for those who took no neuroleptic medication or had it at a later point.
• Is the medication for the sake of the individual or for those around them, including the team?

The group reported an 85% recovery rate for psychosis using this approach. So that, rather than a growing number of people going on from psychosis to be labelled as “schizophrenic”, there are actually very few people with this diagnosis in this area of Finland. It is actually disappearing.

A film-maker called Daniel Mackler has produced a number of videos on Open Dialogue, some of which are available on the web. I particularly enjoyed his interview of Jaakko Seikkula, Professor of Psychotherapy in Finland (author of the article quoted above), in which Jaakko states: “All of us could have psychotic problems! Psychosis is an answer to a very difficult life situation.” 

I was truly impressed by what the Nottingham group had found out so far, and how they conveyed their learning at the workshop. You can find further links to documents about Open Dialogue on our new website page here – and thank you to Nottingham Open Dialogue for sending us some of these. What can we do in Powys to bring this innovative approach a little closer to us…? Do you have ideas about this? Let us know by commenting below.

Meanwhile, to finish….  Monica Cassani, “a social worker and … a person whose life was severely ruptured by psychiatric drugs”, created the BeyondMeds blog and posts about the mental health system in the United States, and alternative approaches such as Open Dialogue. This week in the UK the BBC reported on the need for more psychiatric beds – in England…. I’m inclined to agree with Monica’s view that maybe, if the Open Dialogue approach was widely adopted just as has happened in Western Finland, then the psychiatric hospital beds (wherever they are in the world) would lie empty…

How to Help Loved One w/ Postpartum Depression?

By Nada Stotland, MD, MPH

Postpartum depression simply means depression occurring after childbirth---any time from days after to up to a year after the birth of a baby. 



When we diagnosis depression---at any time in life---we don't mean the kind of "down" mood everybody experiences from time to time. We mean a real disease that causes symptoms including interference with sleep and appetite; thoughts of death; guilt; lack of interest in the activities of life; inability to feel pleasure---every day for weeks. It's a very painful, but fortunately very treatable, disease. 

Depression is particularly painful for a mother with a new baby. People are often telling her that this should be the happiest time of her life, that she should appreciate her good fortune in being able to conceive and bear a child when many others have so much trouble. 



Other people---and even the new mother herself--may also confuse the symptoms of depression with the inevitable interruptions of sleep and meals by the demands of a newborn and the common concerns about being a good mother. 



It's important to distinguish postpartum depression from postpartum psychosis. Postpartum psychosis begins within days after birth. The new mother with postpartum psychosis is seriously agitated, unable to relax. She is haunted by irrational ideas about herself and the baby--ideas, for example, that God wants her to send the baby to heaven or that the baby is a devil of some kind---and sometimes by irresistible urges to harm the baby. Postpartum psychosis is rare; it occurs after far fewer than 1% of births. It is a medical emergency. 



When postpartum psychosis is suspected, the new mother must be seen immediately by a physician, preferably a psychiatrist. 



Postpartum depression seems to be caused by a combination of genetics, the abrupt changes in hormones after birth, physical exhaustion, and the strain of adapting to a new role and the reactions and demands of friends and family. Postpartum depression is often a continuation of depression that was present, but not recognized, during pregnancy. In our society, we take it for granted that we shower medical and social attention on the pregnant woman---frequent visits to the obstetrician, baby showers---when all she has to do for the baby is to take good care of herself. 



After her baby is born---when she is exhausted from labor and delivery and when she has responsibility for the 24/7 care of a helpless infant--all that attention falls away. She may live far away from supportive family members. She may either have to go back to work before she is ready, or may feel isolated, away from the familiar duties and social contacts of the workplace. Usually there are no postpartum visits from nurses, and quality childcare is expensive and hard to find. Postpartum depression, although it occurs everywhere in the world, may be more common in our country for those reasons (occurs in about 15% of U.S. births). 



Postpartum depression can be successfully treated with psychotherapy and/or medication. Group therapy reassures the new mother that she's not alone and others are going through same issues. Family and friends can play major roles in the new mother's recovery. They should remind her that she is not responsible for her depression, and she can recover from it. 



Helping with her baby can be useful, but it's not a good idea to take over baby care completely; that will just make her feel more inadequate. 



It's better to take care of the mother herself. Offer simple diversions, like an outing, but without expecting them to treat depression. We don't want to make her feel unappreciative. Sympathize with her grief over missing the joys of new motherhood. Remind her of all the lovely things she planned and did for the baby before it was born, and point out what a good mother she is working to be. 



Depression makes people feel helpless and hopeless, so she may need encouragement to get the professional care she needs. Friends and family can help by contacting her family physician or obstetrician and by locating a mental health professional available to treat the new mother. With proper care, she will probably start to feel better within a few weeks.

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The Abandoned Illness

"The message that comes through loud and clear is that people are being badly let down by the system in every area of their lives." 
Professor Sir Robin Murray, Commission Chair, The Schizophrenia Commission

This week saw the publication of The Schizophrenia Commission's year long enquiry into schizophrenia and psychosis. It was carried out in England, but is clearly of interest here in Wales, where many of the issues will be relevant. It concluded that a major overhaul of schizophrenia services was required.

You can read and download the report here on the Commission's website. 

There is a BBC news story about the report here.

I first heard about the report early on Wednesday when I woke to Robin Murray speaking on Radio 4's Today programme about how schizophrenia is often triggered by a traumatic life event. He suggested that many people may be genetically vulnerable to developing schizophrenia, but not all do as they may never experience the trauma which could spark the schizophrenia or psychosis. Others do, and that trauma could be anything from bereavement, to losing a job, to witnessing a crime - well, anything traumatic in effect. 

Hafal, the mental health charity, has some useful information about schizophrenia here.

Do you have any experiences of schizophrenia services in Mid Wales? Let us know what you think.

Demystifying Schizophrenia

By Walker B. Shapiro, Medical Student

Reviewed by Claudia L. Reardon, M.D.

You have probably heard of schizophrenia - in newspapers, books, movies, and TV shows; you or somebody you know may be affected with this mental illness. Nonetheless, confusion about schizophrenia is common. This post provides some basic facts about schizophrenia, including common symptoms and available treatments. Schizophrenia is a chronic, treatable brain disease that affects an individual’s thought patterns, behavior, and perceptions of reality.

Some general facts about schizophrenia:

Affects more than 1% of the population with similar rates around the world

Affects men and women with similar frequency

Symptoms usually start between ages 16-30

Most people with schizophrenia are not dangerous or violent

The symptoms of schizophrenia vary greatly between individuals. They can also change and get better or worse over time. Some of the most common symptoms are listed below:

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  Hallucinations – hearing voices is common
  
  


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  Delusions – fixed belief in something untrue or impossible
  
  


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  Paranoia – unhealthy or unfounded suspicion
  
  


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  Disorganized thoughts – may go on tangents or not make sense when speaking
  
  


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  Loss of interest or motivation – may not enjoy daily activities or social interaction
  
  

Schizophrenia is a serious chronic disease, but treatment is available to help people get back to thinking clearly and leading full lives. The most important treatment elements include:

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  Medications (‘antipsychotics’) – help restore and maintain normal, healthy thought patterns
  
  


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  Therapy and rehabilitation – help cope with stress and return to work, school, independent living, and social interaction
  
  

If you are concerned that somebody you know might be suffering from schizophrenia, encourage them to see a doctor for evaluation.

Find more facts on schizophrenia at www.psychiatry.org/schizophrenia.

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The Insanity Defense: Fact or Fiction?

By Molly McVoy, M.D. 

When you hear about a defendant pleading insane at the time he or she committed a crime, what thoughts cross your mind?  You may be thinking of those infamous court cases: John Hinckley, Andrea Yates, Brian David Mitchell (Elizabeth Smart's kidnapper), and most recently, Jared Laughner.  It's common to feel conflicting emotions - anger, confusion, even sympathy - as you remember these high-profile defendants and traumatic court cases.

The word “sanity” is a legal term, not a mental health or clinical term.  Generally, a determination of “sanity” in a court of law refers to whether a “mental disease or defect” (also a legal, not clinical term) causes a person to be unable to know the wrongfulness of his or her action.

Over time, the court clarified what qualifies as a “mental disease or defect,” and it's not always directly related to clinical diagnosis as used by practicing psychiatrists.  Typically, severe mood and psychotic disorders do classify as a “mental disease or defect,” but many other psychiatric illnesses and personality disorders do not.  Courts ultimately determine what illnesses do and do not qualify as a “mental disease or defect” under the “not guilty by reason of insanity” defense. 

The application of this defense has also changed in scope.  Early in American law, only if someone had total loss of memory or understanding would this defense apply.  But in time, that became more liberal -- applying if someone was unable to know the wrongfulness of his or her actions or, because of illness, was unable to resist the urge to commit the crime.

After the attempted assassination of Ronald Reagan by John Hinckley, the standard became narrower once again, returning to apply only to those whose “mental disease or defect” prevented him or her from knowing the wrongfulness of the crime.

Finally, some states have an additional “guilty but mentally ill” statute that affects eventual sentencing but not strict guilt or innocence.  You will probably hear more debate about the insanity defense in media's coverage of Jared Laughner.  There may always be misunderstanding and controversy for this complicated, highly sensitive issue.

 

For more information:

http://www.aapl.org/

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Understanding Psychosis

By  Sara Coffey, D.O.



Often patients and family members have a hard time understanding how a person can be psychotic.  Psychosis is defined as grossly impaired reality testing. Psychosis can be present in several mental illnesses including, schizophrenia, schizoaffective disorder, bipolar disorder and even depression.

The stigma or lack of information surrounding these disorders leaves them feeling guilty or ashamed. I often explain to them that the brain is an organ just like the heart, the kidneys or the liver. And just as our heart, kidneys or liver can become diseased, so can our brain.

The brain is a complicated organ with several different functions. It helps regulate our breathing, our heart rate, and our temperature and handles more complex tasks such as vision and hearing, pain sensations as well as processing complex thoughts or emotions. It is easy for us to understand that if the heart becomes damaged it might not pump as effectively, but it is often harder for us to understand what happens if the brain becomes compromised or unwell. A brain with mental illness may start to hear things that are not there, or experience thoughts that cannot be explained and seem irrational.  A person may become excessively anxious for no reason, or depressed without warning or cause.

In the world of mental illness we use terms to describe such experiences like hallucinations and delusions.  A patient with hallucinations might experience voices talking to them when no one is present. When we recall that one function of the brain is to process and interpret sound it is easy to see how auditory hallucinations might occur if that part of the brain is compromised.

Patients can have delusions that people are out to harm them for no reason, and without proof, or delusions that they are famous powerful figures in history. And again, when we look at how the mind works, how complex processes are taking place that help us navigate who we are and what we do, it makes sense that if something wasn’t working normally in the brain that a person could have a belief that was false.

Although these symptoms might make sense when we look at the brain as an organ, or a tool performing a function, it doesn’t lessen the impact mental illness has on families. Often mental illness takes away what we consider the heart or personality of person and this can be extremely difficult to cope with. Furthermore, the simplicity of understanding is not without criticism. For instance although we are learning more and more about the brain every day, there is still no cure for mental illness, only treatment for symptoms, and often times the treatment cannot fully clear the symptoms of certain diseases.

However, it is important to know that psychosis, like other mental illness symptoms, is not the fault of the person with the illness or the family who cares for them. These symptoms are part of a complex illness that affects patients unwillingly every day.

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